Some cons of PROs

Prophylactic laser photocoagulation in Stickler syndrome

The ocular manifestations in a family with Stickler syndrome and the results of laser photocoagulation as preventive treatment for retinal detachment are described. Forty-two family members with Stickler syndrome were retrospectively reviewed; 22 had ocular abnormalities, 22 had myopia and 16 had high myopia. Ten patients had developed retinal detachment and 9 of them were blind in one or both eyes because of irreparable detachment. Only 2 eyes had been operated on successfully. Ten eyes were lasered prophylactically. In eyes with extensive vitreoretinopathy laser burns were applied 360 degrees around the peripheral retina at the border between the pathological and normal retina. Eyes with isolated lesions received focal treatment around the pathological areas. Four eyes received 360 degrees laser photocoagulation and 6 eyes received focal treatment. Of the treated cases, 9 retinas remained attached for a follow-up period ranging from 1 to 15 years. One patient was lost to follow-up, and 5 years later developed retinal detachment in one eye from a new non-lasered lesion. In conclusion, in this particular family the incidence of retinal detachment was significantly higher in non-lasered eyes than in lasered eyes (p < 0.025).

Circumferential argon laser photocoagulation for prevention of retinal detachment

Circumferential argon laser photocoagulation was administered as preventive treatment for retinal detachment in 53 eyes with extensive areas of lattice degeneration and/or retinal breaks and at least one additional high-risk factor for retinal detachment. Laser burns were applied in several continuous rows 360 degrees around the peripheral retina at the junction between the posterior border of the lesions and the unaffected retina. The retina posterior to the treated areas remained attached in 51 eyes (96.2%) during a mean follow-up period of 85.8 months (range 6 months to 18 years). The treatment did not affect visual acuity. The only complication was the appearance in 2 eyes (3.8%) of a delicate epiretinal membrane which, however, did not require surgical intervention.

Peer review organizations. Promises and potential pitfalls

The Health Care Financing Administration has contracted with 54 peer review organizations (PROs) to monitor hospital use and quality of care for Medicare patients. PROs promised reductions in readmissions, in "unnecessary" admissions or invasive procedures, and in "avoidable" mortality and morbidity. A review of contract summaries for 49 PROs revealed wide variations in reduction targets. In attempting to meet their goals, PROs will encounter numerous potential pitfalls, including inaccurate and incomplete discharge data, inadequate descriptors for the variety of patients and physicians' management plans, honest differences in judgments about patient care, and limited research on the criteria used to set their reduction targets as well as the means to accomplish them. Despite having more explicit quality-of-care objectives, PROs, like PSROs (professional standards review organizations) before them, are more likely to be seen as agents of cost containment than of quality assurance. Both their credibility and their effectiveness might be enhanced if an expert panel of clinicians and health services researchers were established to help them set and achieve reasonable objectives for quality of care.